374604542-8-10-2023-08-AS-RGAZ-CUKNG5-20230810102634

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604542
Report Date: 08/10/2023
Date Signed: 08/10/2023 10:26:38 AM

Document Has Been Signed on 08/10/2023 10:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PACIFICA SENIOR RANCHO PENASQUITOS		FACILITY NUMBER:	374604542
ADMINISTRATOR:	MCDONALD, JILL		FACILITY TYPE:	740
ADDRESS:	12979 RANCHO PENASQUITOS BLVD		TELEPHONE:	(858) 215-5820
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92129
CAPACITY:	120	CENSUS:	DATE:	08/10/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Director Giovanni Arguello		TIME COMPLETED:	10:30 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Case Management visit. LPA identified herself and was welcomed by Concierge staff Kimberly Rios, with whom the purpose of the visit was discussed. Rios called Memory Care Unit and staff Karinna Acosta met with LPA.

LPA informed Acosta that today's visit was in response to an LIC624 Incident Report dated 08/08/2023 submitted by the facility and received by CCLD on 08/09/2023. According to the LIC624: on 08/07/2023, the courtyard door alarm went off. Facility staff initiated a head count. A systematic search of the outside property was performed. Resident #1 (R1) was found walking on the street curb, was redirected back into the facility with no visible injuries noted. [See LIC 811 Confidential Names List for a description of R1.] Facility staff notified R1's physician and daughter.

According to R1’s latest LIC602 Physician’s Report signed and dated 09/15/2022: R1's primary diagnosis is Alzheimer's, Dementia. R1's mental condition indicates wandering behavior, sundowning behavior, but is able to follow instructions and communicate needs. There is no confusion, inappropriate or aggressive behavior. Physician determined that R1 has severe/advance Dementia, and should be escorted by staff when leaving the facility.

R1's Narrative Charting (7/27 - 8/9): 8/7 1:43 PM - R1 was found on the street, care staff (Staff #1 [S1]) assisted resident back into the facility. No visible injuries noted and denies pain. Primary physician and daughter notified. 8/7 8:09 PM - R1 doing good until around 6:00 PM when R1 tried to open doors again around the patio. R1 was successfully redirected. R1's daughter visited later that evening. No issues reported since 8/8. R1 is scheduled for re-assessment today, 8/9.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Riza Gloria Alvarez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR RANCHO PENASQUITOS	FACILITY NUMBER: 374604542
	VISIT DATE: 08/10/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

[CONTINUED FROM LIC 809]

LPA visited R1 at the Memory Care Unit's dining area, where R1 was having breakfast. R1 responded appropriately to LPA's greetings and question - "is the breakfast good?" R1 was in good physical condition, well groomed, and appeared to be enjoying breakfast in the company of other residents.

LPA interviewed S1. S1 found R1 sitting on a street curb approximately 20 (uphill) steps from the exit door. LPA performed a brief facility tour with S1. S1 stated that on 8/7, lunch was served at 12:10 PM. Residents like to take their time while dining. There were 3 exit doors from the dining area, but only one exit door (courtyard) leads to the street. When S1 found R1, R1 said "Hi". Per S1, from R1's facial expression, R1 appeared to know that they did something they should not have. R1 is a sweet person.

Memory Care Director Giovanni Arguello arrived at the facility at around 9:45 AM and showed LPA the facility's Absentee Notification Plan (Clinical 10 - Elopement dated 06/18/2021). The Elopement Plan provides “Should an elopement occur, an immediate systemic search of the property and surrounding neighborhood will take place. The responsible party shall be notified. a) Law enforcement will be notified of the elopement within 30 minutes, should the resident not be located. b) Once the resident is located, the resident's family/responsible party shall be notified, and the resident shall receive a physical examination and physician consult. c) The elopement will be documented. d) The resident will be reevaluated to determine if the resident is appropriate to be retained in the Community, and if so, Service Plan adjustments should be immediately undertaken to prevent further elopements."

There does not exist a preponderance of evidence to show that facility staff did not provide needed care and supervision of R1, or that facility staff did not try to mitigate R1's AWOL (Absence With Out Leave), or that facility staff did not follow the facility’s Elopement Plan. No deficiencies were cited for the above incident, and no deficiencies were observed during today’s site visit.

An exit interview was conducted with Memory Care Unit Director Giovanni Arguello, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Riza Gloria Alvarez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2